In our previous edition of The Ethiopian Herald, Prof. Yifru Berhan, a consultant and researcher at Saint Paul’s Hospital Millennium Medical College and also former FDRE Minister of Health, shared with us, vastly, his expert analysis on the history of influenza pandemics and the tropical epidemics entitled: ‘Will Africa be devastated by Covid-19 as many predicted? Perspective and prospective.’ Here is an exclusive interview with him that aims at further probing into his arguments, and many more.
You worked as Minister of Health, what is your take on the capability of Ethiopian health professionals to respond to Covid-19 pandemic?
Before responding to questions, I would like to express my heartfelt gratitude to my fellow Ethiopian health professionals who are currently on a patriotic mission by managing Covid-19 patients. You give us the confidence and brevity to follow your footsteps if condition compels us to do so. Secondly, in my perspective, cases of Covid-19 may slowly increase in Ethiopia and African tropics, but it is less likely to be an exponential type of increment, as already observed in Europe and North America. Therefore, I would like to bring to the attention of the esteemed readers that my responses to some of the questions may be based on hypothetical number of Covid-19 cases in Ethiopia.
As we learnt from the Europe-America Covid-19 pandemic, the rate of dissemination is extraordinary and unprecedented. Such scale of public health emergency affecting a large population in a very short period of time, and quite a significant proportion of them requiring intensive care service in a hospital setting is very likely to have a catastrophic effect for countries with ill-equipped health facilities. The Ethiopian health system, like many of the Sub-Saharan African countries, may not withstand such kind of emergency flooding, partly because of the extreme shortage of the essential health workforce.
As compared to the predicted Covid-19 patients for Ethiopia, the number of health professionals who are capable of managing the Covid-19 complications (including respiratory failure, kidney failure, disseminated bleeding disorder, stroke) are insufficient, and they are not far from the big towns. Among the critical staff with essential skill to manage Covid-19 and similar cases, emergency medicine specialists are at the forefront. However, this discipline was not given due attention till the first graduates came to service about a decade back.
Care for Covid-19 complications requires 24-hour intensive service, including putting on/off a ventilator (intubating and extubating), which is commonly known to bring about burnout and increased risk of exposure to the virus.
The core point is that we are not in a good position to manage Covid-19 epidemic with its full scale of spread, primarily because of the extremely low essential health professional staff (physician to population ratio for instance is <1 to 10,000).
This is a chronic problem, partly because of the few number of essential health professionals graduated every year, and partly because of the continuous and enormous amount of brain drain in searching for
greener pastures for nearly half a century, for which Ethiopia is not an exception among the developing nations.
Therefore, from the standpoint of the health professionals, what makes their managing capacity somehow compromised is their limited number across the nation, and probably the lack of experience in triaging mass flow with this kind of highly contagious disease. With the ongoing effort at national and regional level to maximize the health cadre for this pandemic response, if the worst comes, Covid-19 managing health professional team can be established in each hospital and treatment centers with short inductive training. That is what is currently in the pipeline.
The health systems of even developed nations have buckled due to the effect of the virus: In this case, how do you view the health infrastructure at home?
Although our modern medical service in a hospital setting dates back to 1896, the progress in the first hundred years was too sluggish. The Italian second time invasion and infrastructure destruction, the first and second world war’s spillover effect, the long lasting civil war, the 1918 Spanish flu pandemic and the recurrent malaria outbreaks were among many factors which were hindering the Ethiopian government’s effort to expand the health facilities across the nation. As a result, the Ethiopian government in collaboration with missionaries and bilateral cooperations was able to construct only 76 hospitals and 279 health centers in just a hundred years.
Practically, the majority of these hospitals (some with 50-80 bed capacity) are now in the range of 50-110 years in service, with no or limited expansion and renovation. Sadly, the new primary hospitals too (constructed in the last two decades) are not that much better than big health centers; the majorities have one operation room and can accommodate 30-40 beds.
Therefore, when we see the available space in the existing hospitals to accommodate Covid-19 like outbreaks, it is highly frustrating. What is flaring up the situation is; neither the majority of the old, nor the new hospitals do have the facility for emergency medical service and intensive care. Organizing emergency medical service is a new initiative in Ethiopia, a bit earlier than a decade. As a matter of fact, none of the existing hospitals
have an emergency medical service unit by design. In the last decade, however, the establishment of an emergency medical service unit by redesigning and renovating the existing outpatient clinics has been attempted in relatively big hospitals, but still with limited capacity. The available medical equipment for emergency medical care are also meager. Let alone Covid-19 like outbreak, the existing space and facilities within the existing hospitals are already far behind the demand of the commonly encountered medical and surgical emergencies. The water sources and electricity in each health facility are disappointing.
How do you evaluate the measures taken by the government in response to Covid-19?
So far so good. Whatever the status of the outbreak is, the preparation made with available resources by assuming the worst to come is appreciable. It is not arguable; when somebody is told that a bushfire is coming to burn his crop on the farm or when he sees a huge blaze of it far away, he has to get prepared with all possible means to extinguish it until he knows that nature can arrest it far there, either by changing the direction of the wind or by showering heavy rain.
That is what has happened and what is happening with regard to COVID-19 pandemic. Every nation has done all its level best to prevent the fire from coming in. There were some nations in Africa, which declared lockdown, even before registering a single case. I do not think, that was wrong as the blaze’s direction and speed of dissemination was unprecedented and unpredictable. Beyond that, by citing credible resources, the international media were repeatedly hammering about the worst effect of the current pandemic in Africa.
Therefore, as the daily warnings and the observed casualties in the Western countries have been very scary, I do not think that the Ethiopian government’s restrictive and instructive actions were exaggerated or suboptimal. In my assessment, the measures undertaken were well organized and focused. The contact tracing and isolating actions, in particular, were exemplary performances, which need to be strengthened. Probably that is why we have the smallest number of cases and deaths as compared to our population size. Implementing neither too tight nor too loose interventions have as well given an opportunity for the government not to be far from the reality on the ground.
On the other hand, the global reality could not be able to give a room for a better preparation, at least in terms of availing essential health commodities for this outbreak. The travel
restrictions, financial constraints and above all the highly contagious nature of the virus have limited the government’s effort.
What challenges do you anticipate and how must the country work to properly respond to a threat(s)?
This is a key question what I like most. I will be focusing on the way forward “after Covid-19”.
With due respect to our success stories in the health sector in the last decade, the anticipated challenges and health risks the African countries in general and Ethiopia in particular may encounter are still multifactorial and multifaceted. Ethiopia is among low income countries which are struggling with double burden of the first and the second generation of diseases (communicable diseases, malnutrition and poor maternal and child health in the first generation, and non-communicable diseases in the second generation). Before it has liberated itself at least from the first generation of diseases, the country is still under higher risk of the third generation of diseases (outbreaks of mutated and/or antibiotic resistant viral and bacterial pathogens, zoonotic/animal origin diseases, substance addiction and psychiatric illnesses, if not that much under threat of biological terrorism).
Geographically, being located near the Equator makes this country at higher risk of the most fatal diseases outbreaks, including the hemorrhagic fever/bloody viral diseases (rift valley fever, yellow fever, dengue fever, Crimean Congo, nipah and Lassa fever), ebola and Marburg viruses. Since 2013, the yellow fever outbreaks are increasing in several places, including Ethiopia. The rift valley fever outbreaks have been occurring in Kenya and South Sudan. Ebola and Marburg viruses are still endemic in central and some Eastern African countries.
Our pride, the Ethiopian Airlines, is flying to almost all hot spot areas where these highly fatal viral diseases are endemic. The world population, in general, is becoming highly interconnected, which speeds up the diseases spread to far areas in hours. Many of these diseases are highly contagious, and do not have treatment or vaccine, with the exception of yellow fever and dengue fever.
Unfortunately, while anticipating the big challenges from these outbreaks, we are experiencing cholera outbreaks, which is the reflection of the poor hygiene and lack of access to safe water.
To make things short, the government and people of Ethiopia have to admit that we are not in a position to manage large outbreaks and mass casualties. Luckily, Ethiopia has not yet experienced huge natural or man-made disasters, with the exception of drought, but that does not mean that we are immune. Therefore, our institutional and logistic preparation has to be with the assumption of that the worst is to be ahead of us.
It is my unwavering conviction that Ethiopia, as potentially the super power of the Eastern and Central Africa, with the second largest population size, needs an institute that can work collaboratively with global health security, and that can carry out disease surveillance, mobilize resources and health workforce for emergency response as
deem necessary in the country and around. Managing outbreaks and mass casualties using task force cannot be a long lasting solution; there should be an institutionalized emergency response. This is a high time to establish the Global Health Security. Ethiopia has to as well take the initiative in establishing the Global Health Security body in the African region, which will be a foundation for the establishment of Global Health Security body, probably as one of the UN agencies.
On the other hand, I think the government and people of Ethiopia have now clearly realized where we are/what we have as far as the health service and health facilities are concerned. The existing hospitals with essential services are not only few in number, but also in their capacity. As noted earlier, a few better functioning hospitals are already overburdened; the capable segment of the population is travelling abroad; the needy are waiting for years for admission in the nearby public hospitals; and quite a significant number of patients are dying while waiting for the clinical care. I cannot be exhaustive in listing the huge problems the public has been facing for decades.
Therefore, the government has to use this opportunity to mobilize resources to change at least 15 of the existing hospitals from “hospital by name” to “hospital by function”, by letting them be able to accommodate each 400-600 beds, standard emergency medical service and standard intensive care unit. Fortunately, the groundwork is already well done (including design development and site selection at different corners of the country).
To materialize this, what it may need is: 1) keeping the current momentum on and use the Covid-19 pandemic as a spring board to jump to the desired goal; 2) taking this project as a priority of action in the years to come; and 3) mobilizing international and local resources. It is again my sincere conviction that there will not be any other better time than this one to come up together and demonstrate our solidarity and perseverance. The already observed public and organizations response to Covid-19 is very impressive and gives me confidence on the local capacity at least to lay down the foundation of the change in the health service. I think Covid-19 clicks everybody’s mind that when the hard time comes, the only option we have is the self-cooperation and self-liberation. Let us put our hands together and build our capacity, which is cheaper, easily accessible and long-lasting. “Hammering while the iron is hot”.
Medical equipment for emergency and intensive care should not worry us much; the current production in the developed world (including in car factories) is extraordinary; many are unlikely to have enough warehouses for the massively manufactured and in the pipeline ventilators and many more types. Therefore, we have to start today in making good preparation to be among the best competitive beneficiaries of the overflow. My firm stand is, while intensively working on Covid-19 containment and mitigation, a parallel initiative has to be launched soon to capacitate the selected hospitals infrastructure.
Overall, without compromising the preventive actions to Covid-19 and many more communicable and non-communicable diseases, the health service has to stand with two legs to save resources (the yearly lost foreign currency by migrating patients) and be in a better position to handle an unavoidable infectious public health emergencies and traumatic mass casualties.
Probing the history of influenza pandemics and the tropical epidemics, in your article published in The Ethiopian Herald, you argued the spread of the virus and its impacts— death, and illness—could not be as severe as it is in the temperate zone. Meanwhile, the WHO believes that over
300, 000 people may lose their lives? What do you comment on this?
It is not only WHO which has predicted the worst for Africa. As one can read from the statements herein, it is very scary and makes hopeless to escape it.
“While most of the world is much richer and healthier, the concern is that it is the poorest people that are going to be hit hardest by the COVID-19 outbreak,” March 4 by Max Roser. “Africa is gearing up for one of the worst pandemics the globe has ever seen,” Access challenge.
Their prediction was in reference to the developed world experience; by taking the ravaging effect of the current pandemic in the first world, particularly in countries with all the potential, many predicted the worst to happen in Africa. So far, the majority could not see this pandemic from a different perspective. Every author or expert in the field has put the chance of this disease spread with equal chance across the globe. Some emphasize it by stating a phrase like “with the exception of Antarctica”. It is true that the virus is already almost in every country, but the magnitude of spread is not yet as predicted.
Little attention is given to the effect of environment and climate condition to viral and bacterial pathogens. There is no need to go to that much detail of the molecular biology of microorganisms to know about the effect of environment and climate to their survival, multiplication and dissemination. Everybody knows that malaria is not everywhere and is not causing outbreaks throughout all the seasons.
I repeat, other human coronaviruses (SARS CoV, MERS CoV, OC43, SADS CoV) and influenza epidemics and pandemics were not able to cause that much deaths in Africa, with the exception of Spanish flu (even that one was too serious in African countries outside the tropical climate zone). Another example is the Swine Flu in 2009-2010; that originated from Mexico which was predominantly in North and South America, West Europe, South and Southeast Asia, and Australia. Among African countries, only Egypt, Algeria and South Africa were part of this pandemic. I am not arguing that Covid-19 will be aborted soon in Africa, but will not have proportional impact to countries in the temperate climate zone.
What is the correlation between the virus and the warmer climate?
Like the macro-organisms, micro-organisms have a different behavior, climate and host preference. Viruses, in particular, may survive outside their host for some time, but cannot multiply unless they get access to the main or intermediate host at variable time. Here is the key point about the fastidious or tolerant nature of the SARS CoV-2 in different weather condition. What we know from other viruses and bacteria behavior, climate has an impact on the possibility of outbreaks. The best local examples are yellow fever, dengue fever, meningitis, malaria and cholera. Change in rainfall, humidity and temperature are known to have a strong impact to the occurrence of
different outbreaks, probably by making the environment conducive for the survival of the microorganism outside the human body or by favoring the breeding of vectors and intermediate hosts.
Therefore, here what I am hypothesizing on the correlation of climate is based on anecdotal evidence and by analyzing the previous pandemics of same family, and by studying the pattern of geographic route of spread of other pandemics in the past. It is also my personal view from what I have observed in the last three months. My hypothesis is that the SARS CoV-2 cannot survive long in the external environment in a warmer and humid weather. I surmise that influenza and human coronaviruses are primarily a temperate climate zone virus; SARS CoV-2 and its cousins, in particular, have negative correlation with temperature and humidity. This hypothesis can be accepted or rejected after carrying out further basic science research on the survival of this virus outside human body at different latitude, gradient of altitude and seasons.
One more, with this regard, Ethiopia and many African countries may as well benefit from ultraviolet radiation (UVR) B exposure. It is well proven fact that ozone depletion, prolonged sunlight exposure, higher altitude and latitude increase the UVR B exposure, of which Ethiopia specifically has double advantage to be protected from Covid-19 like epidemics (high altitude and prolonged sunlight exposure). Living organisms in general and microorganisms, in particular, are at higher risk for UVR B effect. UVR B is known to kill viruses by chemically modifying their genetic material (DNA and RNA). During rainy or cloudy season, 70%-90% of UVR B type is blocked, which may be one of the possible reasons for low incidence of Covid-19 in the African region at this dry season. The effect UVR B on Covid-19 is an agenda of discussion globally.
Why Covid-19 reaches this degree of spread and becomes selective?
There are a lot of unanswered questions that are puzzling researchers. As noted earlier, apart from a dichotomized (North and central) type of the SARS CoV-2 spread, the bizarre course of the disease state of Covid-19 is still enigmatic; among others, the pre-symptomatic virus shedding, recently recognized post-symptomatic prolonged virus shedding and the extra-respiratory organ-systems failure in selected areas and individuals are not yet clearly understood. The less morbid and less fatal nature of this virus to pregnant women and children is still an enigma for many researchers.
Pregnant women, in particular, in addition to the suppressed immunity, the anatomic and physiologic changes with the pregnancy make them vulnerable to viral infections, including the respiratory system. Interestingly, unlike many viruses (including SARS CoV and MERS CoV), SARS CoV-2 is hardly causing serious illness to pregnant women. For the less morbid and almost negligible fatal nature of the Covid-19 in pregnant women, it may be explained by the molecular level study of the immunological changes associated with
Covid-19. With this regard, I have made my analysis and hypothesis, which is already in a scientific journal. The detail may be too technical for the general public audience.
You also warned against complacence as the rainy season is coming particularly in the highlands of Ethiopia? Will it accelerate the transmission?
From experience, we know that viral infections are very common during cold weather, which is again somewhat related to the above question on the effect of climate. The yearly flu-like illnesses (including the historical Spanish flu in Ethiopia/‘Yehidar beshita’) are commonly observed during the late Ethiopian winter and spring (usually between August and December), which is a cold and less humid season for Ethiopia. Similar pattern is observed in many other countries.
The implication is that the viruses can survive longer outside human cells (commonly on the surface of human hands) and get transmitted to other persons during cold and rainy season. Viruses are not only fragile to hot weather but also to hot fluids and hot body temperature. That is why the traditionally well-known treatment for the common cold is steam and warm drinks. With the same analogy, SARS CoV-2 may have a better chance of transmission in the coming Ethiopian winter and spring, particularly in the highland areas, where the humidity is low and UVR B exposure is blocked.
Nearly a week back, multicountry authors analyzed data from three countries and have postulated that the hypoxic nature of high altitude (low oxygen) may compromise the half-live of this virus and in vivo (in human body) infectivity to the cells and multiplication, after they noticed that highland inhabitants are less susceptible to SARS-CoV-2 infection, which is probably the case for Ethiopia. However, unless this is considered as complimentary factor, the hypoxic state of high altitude is always there,
and may not have an impact on the seasonal nature of the viral outbreaks. Whatever the mechanism is, high-altitude is probably an advantage for less risk of Covid-219. The majority of European countries being at or near sea level perhaps has increased their susceptibility to Covid-219.
The message is; we are still at increased risk of further spread of this disease, particularly, when the weather condition becomes favorable for the virus spread in the months to come.
Do you think the world has remained ignorant of the impacts of potential pandemics while spending in billions and realizing fast global interconnectivity?
Well, I think, the answer for this question is not simple and straightforward. It may be explained by the social science theory of “The Unintended Consequence of Purposive Action”. One thing what I agree with many environmentalists is the less attention given to climate change by the industrialized world and the progressively warming world, which is partly attributed to the increasing occurrence of zoonotic diseases in the middle and low-income countries, while the globalization has been growing with alarming rate.
Although I am not in the field to comment on it, the fast globalization or global interconnectivity is still related to the climate issue, fast population growth in low and middle income countries, global trade and intercontinental tourism, which all are contributing factors for high mobility of the global population. Industries have been translocated from high income countries to low and middle income countries to find low wage workers and more than that to be free from climate roars back at home.
In my opinion, the global connectedness has not been established by design, rather by default, primarily spearheaded by technology advancement and secondly, by the achievement of demographic dividend in many middle income countries. I do not think that the established globalization is regrettable or reversible. Many countries across the globe have closed their borders and avoided international travels as a response to Covid-19 pandemic. Any further similar action is likely to bring about economic crisis worldwide, as the foreign investment and foreign asset are critical for their macroeconomy. But, it is difficult to judge that they have already anticipated this kind of pandemics in the 21st century. Still many worse things may be experienced while going for good (economic development).
Therefore, as pointed out above, what is essentially needed is establishing a Global Health Security to liaise and coordinate the global response for similar outbreaks. Secondly, the global response should not only focus on managing crisis; rather, much emphasis has to be given in preventing the occurrence of such outbreaks, by recognizing any infectious agent currently anywhere as a global threat, and investing on vaccine and therapeutic agent development. Governments, pharmaceutical companies and philanthropies have to come together to support infectious disease researchers.
The Ethiopian Herald May 1/2020
